The Intersection of Critical Care Cardiology and Advanced Heart Failure Cardiology
The Intersection of Critical Care Cardiology and Advanced Heart Failure Cardiology
Critical care cardiology is a new, growing subspecialty within cardiovascular medicine. How can advanced heart failure cardiologists and critical care cardiologists coordinate care in the CICU of the future? The Cleveland Clinic’s Ran Lee, MD, shares his special perspective. Having completed training in both subspecialties, Dr. Lee is one of a handful of people with true expertise to speak on this topic. Here, he shares his personal experiences as well as his design of the CICU of the future.
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Content
2.48 -> all right everybody thanks for joining
3.6 -> us again this week um
5.68 -> we have a really interesting talk i
8.24 -> think i'm really excited to
10.32 -> to hear uh what dr lee has to share with
12.88 -> us today
14.08 -> um so just a little bit about a little
15.519 -> bit of background um
17.6 -> about uh where this talk came from um as
21.68 -> as plenty of you know uh our cicu is
25.519 -> going through restructuring
28.08 -> uh where us as advanced heart failure
30.96 -> cardiologists will be working side by
32.8 -> side with critical care cardiologists
35.44 -> and as you will see
37.36 -> um dr lee has a very special
40.719 -> training and background to help us
42.719 -> navigate this new uh situation
46.32 -> so uh dr randlee
48.559 -> care and heart failure transplant
51.039 -> cardiologist at the cleveland clinic
53.44 -> uh he completed his cardiology and heart
56 -> failure training at cleveland clinic
58.079 -> where then state uh sorry he completed
60.559 -> his cardiology and heart failure
61.92 -> training at the university of michigan
64.239 -> uh prior to obtaining his critical care
66.56 -> training
67.6 -> at the cleveland clinic
69.28 -> and then he has stayed there at the
70.64 -> clinic on as faculty
73.68 -> his clinical interests are in
75.28 -> cardiogenic shock
77.04 -> temporary mechanical circulatory support
78.96 -> systems of care and quality initiatives
80.72 -> in the icu
82.24 -> so i'm very grateful that dr leah's uh
85.6 -> decided to join us today and uh
88 -> ryan please the floor is yours
90.56 -> great um
91.84 -> uh good afternoon i just want to verify
94.24 -> audio and visual are all okay slides are
97.04 -> coming through all right everything
98.72 -> looks really good perfect um good
100.88 -> afternoon uh thank you uh michael uh and
103.92 -> yale for uh extending the invitation to
106.079 -> come speak with you all today um so
108.24 -> today uh i really wanna
110.399 -> kind of talk about a topic that's near
112.399 -> and dear to my heart obviously i went
114.24 -> through the training to
116.24 -> do both but really kind of the
118.32 -> intersection of critical care cardiology
120.079 -> and advanced heart failure cardiology
122.56 -> is what we'll be spending the next hour
126.32 -> we'll go over these topics uh really the
128.239 -> argument for critical care cardiology
130.56 -> the role of the cardiac intensivists
132.08 -> with respect to advanced heart failure
133.84 -> different staffing paradigms for cicus
137.44 -> talking about different
139.12 -> training pathways education and
140.8 -> scholarship within this
142.64 -> growing field and what i think really is
145.28 -> the ideal state in the next four to five
147.599 -> years
149.84 -> so the first kind of quote-unquote ccu
152.56 -> really started as a coronary care unit
154.64 -> units
156.239 -> where you know rapid defibrillation cpr
159.68 -> and continuous ecg monitoring were the
162.4 -> mainstays of therapy
164.48 -> so the first concept of a ccu was
167.36 -> articulated to the british thoracic
169.2 -> society back in 1951
171.519 -> and following that the first ccus were
173.76 -> established in north america a pillow of
177.599 -> killer class fame
179.28 -> reported on
181.04 -> one of the first experiences with ccu
183.28 -> patients really talking about about 250
186.72 -> where he was able to decrease the
188.4 -> mortality rate from 26 percent down to 7
192 -> in their ccu
194.08 -> and
194.959 -> a year later the advent of one of the
197.04 -> first mechanical circulatory support
199.12 -> devices in the intra-era balloon pump
201.12 -> was developed to treat acute myocardial
203.44 -> infarction in its complications so
205.92 -> really kind of the early 60s
208.08 -> saw the advent of
209.76 -> what began to be the development of
213.44 -> the cardiac intensive care unit where at
215.519 -> least the beginnings thereof
218.56 -> over time as we've seen advances in
220.959 -> technology medical care
222.959 -> training and organization and population
226.72 -> and that kind of rapid resuscitation
228.72 -> units really focused on arrhythmias and
230.959 -> ventricular
232.4 -> issues
233.599 -> as complications of acute microvariable
235.68 -> infection
237.28 -> began to change into kind of a
239.519 -> comprehensive
240.4 -> critical care unit that we
242.239 -> know and love dearly today
244.56 -> where not only
246.72 -> are we seeing advances in technology but
249.12 -> patient population and the ability of
252.159 -> technology and our expertise
254.48 -> in
255.599 -> not only diagnosing and monitoring but
258.32 -> treating patients
259.759 -> with things such as advanced ventilation
262.32 -> targeted temperature management and
264.08 -> mechanical circulatory support
267.44 -> so here are a couple of things that i um
270.96 -> and you all
272 -> see on a daily basis with respect to the
274.56 -> the changing cicu so moving from a
277.68 -> coronary care unit or ccu to a true
280.24 -> cardiac intensive care unit where we
282.479 -> have higher rates of elderly women in
285.36 -> minority populations we have increasing
287.44 -> prevalence of comorbid conditions such
289.44 -> as diabetes hypertension
291.52 -> renal failure obesity and obstructive
293.84 -> lung disease and we are increasingly
296.32 -> using both invasive monitoring as well
298.56 -> as invasive treatment devices uh all
301.28 -> carrying their risk of potential youtube
303.52 -> complications but also a therapeutic
306 -> benefit
307.44 -> and then as a result of doing all this
309.84 -> we are changing the natural history of
312.4 -> critical illness um
314.72 -> as it arrives to our doors um
317.759 -> we are as you uh all experience on a
320.639 -> daily basis with the advent of
322.08 -> structural heart disease and structural
323.52 -> heart interventions we are changing this
326.639 -> paradigm as well
328.8 -> jason katz really who you kind of refer
331.28 -> to as the godfather of the modern kind
333.28 -> of critical cardiology movement
337.28 -> first really reported this back in 2010
340.24 -> just looking at the duke
342.24 -> coronary care unit and the changes in
344.479 -> diagnosis over time so as you can see
347.68 -> there's a decline in stemi diagnosis
351.12 -> somewhat of a rise in non-stemi
352.88 -> diagnoses but increases in cardiogenic
355.28 -> shock as well as congestive heart
357.36 -> failure
358.639 -> and with that
360.24 -> kind of those comorbid conditions that i
362.08 -> talked about respiratory failure renal
364.16 -> disease
365.199 -> sepsis pneumonia
367.44 -> as well as how we treat them between
370.319 -> prolonged mechanical ventilation ibps
373.6 -> central venous catheterizations they've
375.36 -> all increased
376.96 -> over kind of the previous decade
379.919 -> interestingly you can probably notice in
382.639 -> this kind of more outdated
385.36 -> data set the swan gang's catheter
388.479 -> decreased in use kind of in the 2000s
391.199 -> with respect to
392.8 -> some of the trials that came out such as
394.4 -> escape
395.84 -> but we've definitely seen over the last
397.919 -> decade the 2010s to 2020
400.88 -> time frame that the pa catheter is
403.36 -> increasing in use once again
406.479 -> further corroborating that with more
407.919 -> kind of contemporary evidence the
409.36 -> university of virginia analyzed around a
411.84 -> thousand admissions between 2013 2014
415.44 -> really trying to display out what the
417.759 -> population looks like now and as you can
419.84 -> see acute coronary symptoms which were
422.16 -> the bread and butter back in the 60s are
424.08 -> now just a quarter
426.479 -> roughly of the admitting diagnoses to
429.44 -> the cardiac intensive care unit with a
431.599 -> heavy heavier contribution from heart
434.08 -> failure valvular disease
436.8 -> and kind of a smattering of other things
439.12 -> such as atrial tachyarrhythmias or
441.599 -> ventricular tachyarrhythmias
443.84 -> the prevalence of kind of st elevation
447.039 -> mis versus non st elevation mis also has
449.919 -> changed over time in the
452.639 -> primary pci era with early recognition
455.759 -> and advanced systems of care in the
457.84 -> pre-hospital setting
460.4 -> more importantly out of this analysis
463.199 -> the investigators were able to
465.12 -> demonstrate that
467.68 -> yes these patients are ill and they're
469.919 -> presenting with non-mi related things
472.72 -> but those cool morbid conditions get to
475.52 -> be strongly associated with outcomes
478.639 -> so acute kidney injury acute respiratory
480.879 -> failure or sepsis the presence of any of
483.919 -> these chromomorphic conditions
486.4 -> in a hospital stay will
489.12 -> worsen your mortality will prolong your
491.28 -> hospital stay by almost up to a week um
494.96 -> and so
496 -> these are increasingly prevalent in
497.919 -> things that we as cardiologists need to
500.639 -> pay more attention to because they occur
503.919 -> the admissions that they were
506.4 -> analyzing
508.96 -> um so
510.479 -> uh in the in the mid 2010s uh
514 -> jason katz kind of published an article
516.8 -> kind of talking about the maturation and
519.2 -> the future of critical care cardiology
521.12 -> and you can see that the modern day cicu
524.399 -> and micu have a lot of common diagnoses
527.76 -> and patient characteristics
530.959 -> that converge right in the middle of
532.64 -> this venn diagram
534.56 -> but where the cic really diverges
538.399 -> happens to be with temporary mechanical
541.04 -> circulatory support the structural heart
542.959 -> interventions that i mentioned
544.8 -> durable lvads as well as kind of the
546.8 -> more invasive human dynamic monitoring
548.8 -> with pa catheters that we're more
550.64 -> familiar with in the cicu
554.64 -> and really just hammering this point
556.399 -> home
557.279 -> shashank sinha one of my co-fellows
559.839 -> at michigan published in in 2017
564.16 -> looking at the changes in primary
566.16 -> diagnoses in the cicu
569.12 -> medicare beneficiaries over the previous
571.44 -> decade
572.56 -> as you can see in the percentage bar
574.88 -> graphs the increase in gi infectious and
577.839 -> respiratory diseases as a percentage of
580.08 -> diagnoses and the decrease in coronary
582.959 -> disease
584.16 -> from 2003 to 2013 is pretty market
588.8 -> dysrhythmias congestive heart failure
590.48 -> valvular disease kind of
592.24 -> are static slash
594.48 -> slightly increasing but those primary
596.72 -> non-cardiac diagnoses are really
599.839 -> what this paper really hammers home
604.079 -> as a result um
606.48 -> kind of jason katzen and others
608.71 -> [Music]
610.56 -> with respect to the kind of critical
613.12 -> care group out of brigham
615.12 -> wrote a scientific statement in 2012
617.44 -> looking at well what does
619.92 -> the modern cicu need from medical
622.72 -> staffing and training both from nursing
625.519 -> and
626.399 -> physician standpoint
628.16 -> so they defined a level one cicu as able
632 -> to do
633.2 -> pa catheter monitoring able to do
635.2 -> bedside echo
636.72 -> able to do invasive arterial line
638.56 -> monitoring should be able to have
640.24 -> mechanical ventilation should be able to
642.32 -> have rapid response temporary support
645.36 -> and then staffing really comes down to
647.6 -> you know either a cardiac intensivist
649.6 -> which back in 2012 was really a novel
652.24 -> idea
653.76 -> and not that many people who had gone
655.68 -> that pathway
657.12 -> as opposed to 2021
659.44 -> or kind of a micu
662.079 -> person who worked with an intensivist um
665.76 -> and really just having an attentiveness
668.079 -> there
669.92 -> for a very long time
672 -> or you know almost 24 7 and
675.12 -> low r into patient staffing ratios as
677.519 -> well whereas kind of level two level
679.519 -> three c i c use could be cardiologist
682.64 -> run or intensivist run
685.6 -> so the real question becomes does having
688 -> a cardiac intensivist matter
690.64 -> obviously i'm you know personally biased
692.88 -> otherwise i wouldn't have done the
694.16 -> training myself but this has actually
696.32 -> been published on and so this was a
698.24 -> paperback in jack that looked at the
700.079 -> association granted not causality but an
702.959 -> association of a cardiac intensivist and
705.839 -> outcome so this study came out of south
707.6 -> korea
708.8 -> where patients were
710.399 -> in an open model and then in 2013 they
713.04 -> changed to a closed model and you can
715.04 -> see the reduction in cardiovascular
717.44 -> deaths both in the cicu as well as in
720.079 -> the hospital later on during the length
722.24 -> of stay
724.16 -> so both in cardiovascular deaths and
726.079 -> non-cardiovascular deaths going from a
728.72 -> more open
730.56 -> just routine cardiologist versus a
732.56 -> specific cardiac intensivist model
735.6 -> and on a more granular level
738.639 -> looking at the outcomes with respect to
740.48 -> sepsis feeding malignancy
743.36 -> were all improved upon with kind of this
746.079 -> high intensity intensive staffing model
749.839 -> going from an open model to a closed
752.24 -> model
754.24 -> so this was
755.68 -> looked at over a four year time frame
758.32 -> where they did a pre and post analysis
760.72 -> to come up with this
762.8 -> along the way national
766.48 -> groups such as leapfrog which kind of
769.92 -> accounts
771.04 -> ratings to hospitals and
773.279 -> safety
774.399 -> metrics to hospitals
776.399 -> really have come out
778 -> with recommendations on how to staff
781.04 -> icus all comer icus
784.16 -> with the idea of having true
786.16 -> intensivists
787.68 -> who are board certified in critical care
790.079 -> who provide at least six weeks of
791.68 -> full-time icu care that being said i
794.959 -> came from an institution that
797.44 -> didn't really adhere to the intensivist
799.92 -> part of it
801.519 -> but did adhere to the
803.44 -> the attendings who work in the cicu
806 -> really need to do at least six weeks of
807.68 -> full-time icu care each year rather than
811.839 -> someone dropping in for two weeks out of
814 -> the calendar year and saying that that
816 -> was sufficient to be a cicu
819.44 -> attending
820.959 -> but this carries weight because we
823.199 -> changed our model in michigan
825.839 -> to make sure that if you couldn't
827.04 -> provide those six weeks whether you were
829.199 -> in the cath lab or otherwise um you
832.399 -> really couldn't round in the cic so
836 -> big groups like this that afford ratings
838.16 -> to hospitals and icu's do matter
840.8 -> can carry a lot of weight and how they
842.639 -> do it
844.399 -> so what so you know we've emphasized the
847.839 -> importance of the changing population
849.92 -> we've talked about the evidence of
851.92 -> benefit of intensivists so where does
853.839 -> advanced heart failure come into play
856.639 -> so specifically i'll talk about what we
858.72 -> have here at the cleveland clinic where
860.639 -> we have a dedicated heart failure icu so
863.36 -> our heart failure icu
866.8 -> 10 bed icu
869.199 -> right adjacent to our cardiac icu which
871.92 -> is 24 beds so
874.8 -> few centers employ a dedicated heart
876.959 -> failure i see where
878.56 -> all the patients are specifically
880.88 -> advanced heart failure patients
883.04 -> but we are able to provide in our
885.199 -> failure icu invasive hemodynamics
887.76 -> temporary mechanical circulatory support
889.76 -> including bloom pumps and impella
892.32 -> with conversations that are ongoing
894.56 -> about escalating to ecmo but we're not
897.04 -> there yet we are however able to provide
900.32 -> the nursing
901.519 -> fellow and attending
903.76 -> level of care for our lvad patients
906 -> whether they are
907.44 -> kind of in the index hospitalization but
909.76 -> maybe not fresh post-op
911.839 -> as well as the post-transplant patient
913.519 -> who's dealing with complications
915.519 -> requiring an icu
918.48 -> however not every attending in our heart
921.279 -> failure icu is a quote-unquote
923.519 -> intensivist so this kind of gets back to
926 -> well is this because there just aren't
928.399 -> enough of us around or do we really feel
930.48 -> like every person who rounds in the
932.16 -> heart failure icu need to be quote
934.32 -> unquote and intensivist or critically
936.24 -> care trained
937.44 -> so here are the benefits and here are
939.6 -> the downsides of having
941.68 -> um
943.519 -> heart failure isu that's not necessarily
945.759 -> staffed by
947.6 -> quote-unquote cardiac intensivist so
949.68 -> what we're all really good at in heart
951.839 -> failure and transplant and bad are shock
954.88 -> human dynamics being able to
956.8 -> troubleshoot temporary mechanical
958.24 -> circulatory support with different
960.48 -> variations and gradations of expertise
963.68 -> and obviously being able to weigh in on
966.399 -> patient candidacy for advanced therapies
969.199 -> what people
970.48 -> my colleagues who are not intensive care
972.639 -> trained may be less familiar or
974.72 -> comfortable with would be advanced
976.72 -> ventilator management airway support
978.88 -> including intubations bronchoscopies and
981.44 -> plural based procedures or plural based
983.759 -> diseases which do coexist with our
986.399 -> patient population although not as much
989.12 -> as the
990.16 -> kind of broader cardiac icu population
993.44 -> so we get several types of patients in
995.839 -> our heart failure icu really coming down
998.32 -> to
999.04 -> the listed patient or the patient
1000.88 -> undergoing advanced heart failure
1002.48 -> evaluation
1004 -> our lvad or post-transplant patients
1006.48 -> and then kind of our routine bread and
1008.56 -> butter heart failure patient who needs
1010.72 -> to undergo some tailored pa catheter
1013.44 -> management obviously we try to give
1015.36 -> preference to the first two buckets of
1020 -> patients
1021.279 -> in terms of bed allocation resources as
1024.079 -> we only have 10 beds in the heart
1026 -> failure icu but
1027.839 -> we can talk a little bit about
1030 -> you know if you build it they will come
1031.6 -> kind of a model where a lot of patients
1033.679 -> where a lot of individuals will want
1035.679 -> their patient in for a routine tailored
1038.319 -> pa catheter management
1042.319 -> so on top of this
1044.559 -> people have actually studied and looked
1046.959 -> into
1047.919 -> does having a quote unquote heart
1049.84 -> failure physician not necessarily a
1052.24 -> cardiac intensivist in the cicu matter
1055.039 -> and if there's a difference in outcomes
1057.84 -> the journal of cardiac failure in
1059.76 -> october had a special
1063.039 -> focus issue on kind of what they call
1065.6 -> the nexus of her failure
1067.84 -> in critical care cardiology so this is a
1070.48 -> very topical on the minds of a lot of
1073.2 -> individuals
1076 -> area
1077.679 -> and so i'm glad that i've been invited
1079.919 -> to kind of give my two cents and
1082.72 -> have a further discussion on this but in
1085.36 -> that journal
1087.039 -> issue
1088.559 -> this article came out of montefiore in
1091.28 -> the bronx looking at full-time cardiac
1094.24 -> intensivist care staffing by her failure
1096.64 -> specialists and its association with
1098.72 -> mortality rates so similar to that south
1100.64 -> korea study they went from an open unit
1102.96 -> model to a closed unit only run by her
1106 -> failure folks so not interventionalists
1108.559 -> not general cardiologists
1110.48 -> uh not necessarily intensivists but
1113.28 -> advanced heart failure transplant
1114.559 -> physicians and there's no doubt that you
1117.44 -> know
1118.16 -> that they were able to prove
1119.76 -> retrospectively
1121.6 -> there was an association with the
1122.88 -> decreased mortality
1124.64 -> with the presence of
1126.48 -> heart failure attendings in the unit
1128.32 -> rather than an
1129.679 -> open model
1131.039 -> whether or not you compared it to kind
1133.52 -> of an interventional only model or a
1135.44 -> general cardiology model would make a
1137.84 -> difference is
1139.28 -> unclear because that's not how they
1141.28 -> did their study and that's not how they
1142.88 -> ran their units but
1144.559 -> this is kind of piggybacking on that
1146.32 -> south korea jack study that
1148.96 -> well
1149.76 -> if you look at a specific type of
1151.28 -> cardiologist in the cicu
1154.08 -> what difference does it make so um this
1156.559 -> furthers the cause for
1158.48 -> advanced heart failure positions to
1160.08 -> round in the icu
1161.919 -> tom mecus at hopkins uh and his group
1164.88 -> really published uh in that same issue
1167.44 -> on well what is the spectrum of heart
1170 -> failure in the icu so there's kind of
1172.559 -> the
1173.679 -> dominance nuances or myocarditis stress
1177.2 -> cardiomyopathy type patient or there's
1179.76 -> the secondary heart failure patient
1182.08 -> there's the advanced heart failure
1183.44 -> therapy patient but then there's also
1185.12 -> the non-cardiac organ failure that needs
1187.2 -> to be
1188.4 -> adjudicated and taken care of in the
1190.24 -> heart or icu as well
1193.12 -> and we see this kind of on a daily basis
1195.919 -> here at the cleveland clinic
1199.36 -> if you look at
1201.039 -> what has existed in the past
1204.4 -> prior to the advent of cardiac
1206.32 -> intensivists a lot of uh surveys that
1209.28 -> have been sent out
1210.72 -> really
1211.679 -> run the gamut in terms of how cxus are
1215.039 -> staffed and so this was a
1217.28 -> meta-analysis of their buddies looking
1219.44 -> at high versus low intensity
1221.919 -> icu staffing and what they really proved
1224.48 -> that the the folks who had high
1226.159 -> intensity staffing with clinical
1228.24 -> intensivists
1229.52 -> did better
1231.36 -> but if you look at the individual
1232.96 -> granular level
1234.64 -> not many of these icus had that kind of
1237.76 -> quote unquote intensive staffing and it
1240.559 -> really kind of begs the question
1243.28 -> or at least it did back then how do we
1246.24 -> push the envelope to say we have
1248.159 -> evidence that it's beneficial but our
1251.44 -> practice patterns haven't caught up to
1253.12 -> it it really depends on a lot of
1254.96 -> different things whether you're in an
1256.4 -> academic tertiary center whether in your
1258.48 -> community hospital whether or not you
1260.48 -> just have the resources to provide that
1262.24 -> level of staffing
1264.4 -> i um in my heart failure year i did a
1268 -> tour of different icu's up in the
1271.12 -> northeast
1273.12 -> and some of you may be familiar and kind
1275.52 -> of compared to to where i was going to
1277.919 -> be at cleveland clinic for my critical
1280.24 -> career and different places do things
1283.36 -> differently and
1284.96 -> really kind of comes down to local
1286.96 -> culture
1288.72 -> what has been done experientially and
1290.96 -> where the expertise is so most notably
1294.159 -> tufts has a co-intensivist model where
1297.36 -> there's
1298.48 -> intensive care physicians who co-manage
1301.36 -> the cardiac critical care patients with
1303.84 -> cardiologists whether that's general
1305.919 -> cardiology or heart failure or
1307.12 -> cardiology um so there's always an
1309.919 -> intensivist in-house
1311.6 -> or at least providing coverage 24 7
1314.88 -> but that intensivist is not a
1316.72 -> cardiologist that's a critical care or
1319.12 -> anesthesia trained intensivist
1322.32 -> at
1323.6 -> mgh
1325.2 -> they also employ not only cardiologists
1328.799 -> cardiac intensivists but anesthesia
1330.96 -> intensivists
1332.64 -> especially with patients who are kind of
1335.6 -> are advanced heart failure temporary or
1338 -> durable mechanical circulatory support
1339.919 -> type patients and they were able to
1342.32 -> handle up to kind of centromags
1344.799 -> but on the anesthesia intensivist side
1347.76 -> of their unit
1349.919 -> and then in
1351.6 -> for for here at cleveland clinic
1354.4 -> we have a 24 bed cardiac icu that
1356.88 -> handles up to va ecmo
1359.52 -> impellers we don't do tandem heart
1363.6 -> that goes to the cv icu but we are in
1366.4 -> conversations to bring that to the
1368.48 -> cardiac icu
1370.4 -> but then our heart failure icu is 10
1372.08 -> beds that handles impellas
1374.64 -> but not ecmo we handle lvads and
1379.76 -> this is kind of how
1382.159 -> this is how our split
1384.159 -> looks like at gluten clinic
1388.32 -> i'm going to go on to the next
1390.88 -> uh section but before i did i wanted to
1393.76 -> ask if there were any questions before i
1395.52 -> moved on
1399.2 -> hey rad this is tarik i have a quick
1400.96 -> question so
1402.4 -> um you know supposing you have
1405.52 -> you know with the balloon pumps like
1408.559 -> in the the the use of balloon pumps or
1411.2 -> swans to get people transplanted
1413.679 -> if patients are sitting in the icu for
1416.24 -> for a very long time like
1418.64 -> what do you guys do with workflow so
1420.96 -> you know with ten beds like if five or
1422.48 -> six are taken what's what's the other
1424.4 -> option
1425.52 -> yeah so that's um that's a very good
1427.84 -> question and that's kind of i alluded to
1430.64 -> some
1431.52 -> um
1433.039 -> i alluded to this earlier where
1435.84 -> that
1436.64 -> since 2018 with the change in allocation
1439.44 -> we are seeing a lot of that and
1442.24 -> a lot of people are using balloon pumps
1444.24 -> across the nation to get their patients
1448.24 -> upgraded and then transplanted
1451.2 -> we've occasionally had to utilize the
1453.679 -> cardiac icu for beds
1456.48 -> for our kind of axillary balloon pump
1458.4 -> waiters uh until they were able to get
1460.72 -> into the 10 bed icu
1462.799 -> um but that
1464.96 -> has led to some tension and and i think
1467.12 -> that has to do with
1469.2 -> well
1470.159 -> you know you create a dedicated heart
1472.4 -> failure icu
1473.919 -> um why aren't you using it and so
1476.88 -> um
1477.76 -> that part of it gets to be
1480.64 -> potentially
1482.4 -> contentious with your other kind of
1484 -> cardiology colleagues usually we play
1486.159 -> very nice in the sandbox and try to
1487.84 -> accommodate but we do run out of room
1491.2 -> and we do have to incorporate the
1493.039 -> resources that we have which gets to be
1496.799 -> you know a question of how does heart
1498.88 -> failure interface with the rest of kind
1501.36 -> of cardiology and cardiac critical care
1505.039 -> so education nursing protocols really
1508.08 -> get to be important on taking care of
1510.32 -> these temporary mechanical circulatory
1512 -> support patients but oftentimes we do
1515.279 -> have to kind of essentially board
1517.76 -> patients in the cardiac icu until a bed
1520.4 -> is available in the 10 bed heart failure
1523.039 -> icu
1524.88 -> that's the benefit of having more beds
1527.12 -> in spaces but a lot of people a lot of
1530.159 -> places can't do that and so kind of
1532.799 -> judicious use of
1534.64 -> pa catheters for your non-listed
1537.279 -> patients or your non-evaluating patients
1539.76 -> gets to be
1541.52 -> important
1542.4 -> so you know at different institutions
1544.32 -> you have
1545.279 -> kind of these
1546.799 -> swan beds where they're not taken care
1549.039 -> of in an icu but are more in an
1550.88 -> intermediate care setting so the
1552.48 -> question is how much of that can be
1554.159 -> offloaded so that you can open beds in
1556.159 -> your heart failure icu
1558.799 -> but we do have crossover so
1561.36 -> one other question uh because this is
1563.36 -> very interesting you might have already
1564.64 -> mentioned this
1565.919 -> um
1567.039 -> actually two questions was there any
1568.64 -> pushback if you try to get va ecmo
1571.44 -> into a medical kind of cardiology icu
1575.279 -> uh from you know
1577.679 -> nursing staff others
1580.08 -> and what do you guys do in the procedure
1582.08 -> room
1583.12 -> yeah um i'll answer the second question
1586.08 -> first because that's pretty that's
1587.44 -> simpler um well so in our procedure room
1591.039 -> we
1591.76 -> do
1592.48 -> your routine master access but we do
1594.72 -> balloon pumps in our procedure rooms or
1596.48 -> our general fellows um
1598.799 -> are trained to do balloon ponds without
1600.72 -> the presence of interventional
1601.84 -> cardiology under the supervision of
1603.76 -> myself
1604.96 -> or some of the other cardiac
1606.4 -> intensivists or the heart failure group
1608.72 -> as well
1609.84 -> are pretty adept at doing them here
1612.48 -> so we do balloon pumps temporary
1614.24 -> peacemaking wires with active fixation
1616.24 -> pericardius and tcs
1618.159 -> uh routine vascular access
1621.039 -> all in our procedure room and then the
1622.799 -> first question about va ecmo
1625.919 -> so when i came that had been ingrained
1628.72 -> here for a very long time and i think
1630.96 -> our nursing education
1632.72 -> leader
1633.84 -> who has since retired is deb klein who
1636.799 -> sits on a lot of the aha kind of acute
1640.159 -> care committees and so she was a
1642.32 -> champion from the get-go for via ecmo
1645.44 -> and really devised a lot of our nursing
1648.32 -> education protocols so for as long as i
1651.36 -> know anyways that's
1653.6 -> since been grandfathered here for a very
1655.679 -> long time and i think a lot of it
1657.919 -> also has to do with our interventional
1659.76 -> group
1660.559 -> places via acmo so we have kind of joint
1663.36 -> ownership on
1665.76 -> taking care of these patients between c2
1668.159 -> surgery and
1669.84 -> interventional cardiology
1671.76 -> and cardiac critical care
1674.399 -> not many places have the resources
1677.6 -> to do that my previous institution at
1679.6 -> university of michigan we had a 10 bed
1682 -> icu
1683.2 -> and so we couldn't take more than
1685.2 -> impella
1686.72 -> nor did we have the expertise to do so
1689.36 -> but in growing
1691.039 -> a program that can take different levels
1693.2 -> of mechanical circulatory support having
1695.6 -> a nursing champion really helped with
1698.24 -> devising the protocols for training
1700.96 -> the 10 bed heart failure icu we've been
1703.279 -> talking about getting
1706.559 -> the act mode there
1708.32 -> over the last several years but
1710.72 -> i think just because the the nursing
1713.919 -> um
1716.64 -> cadre
1717.84 -> cohort in that heart failure icu is a
1720.559 -> little
1721.52 -> less
1722.48 -> in terms of the number of people who are
1725.2 -> routinely there it gets to be a little
1727.12 -> bit harder
1728.399 -> to implement but it's an ongoing
1730.48 -> conversation
1732 -> and something that we do want to do
1733.52 -> eventually
1739.039 -> um
1739.84 -> moving on
1741.12 -> so then the question if if we talk about
1743.36 -> cardiac intensive as being the future
1746.159 -> um
1747.279 -> another really kind of on topic
1750.32 -> perspective is how do we develop them um
1753.12 -> so
1754.24 -> in 2015 uh co-cats really
1757.679 -> started to put out what would level
1760.64 -> three certification and critical care
1762.799 -> cardiology look at look like
1765.6 -> so they dictated that really it involves
1768.08 -> completion of a one-year clinical
1770.08 -> fellowship in critical care in addition
1772.32 -> to a three-year cardiovascular medicine
1774.399 -> fellowship
1776.399 -> and along the way the focus really being
1778.72 -> on acquisition of skills defining
1780.88 -> competencies credentialing which is a
1783.6 -> very important point and continuing
1786.24 -> medical education in that one year of
1789.52 -> critical care cardiology training
1792.799 -> shashank and others um from the
1794.96 -> university of pennsylvania kind of
1796.48 -> delineated what their pathway looks like
1799.2 -> at penn with a a fourth year of critical
1802.64 -> care
1803.679 -> so you can see some of the different
1806.48 -> selected rotations between
1808.159 -> cardiothoracic icu medical icu
1811.44 -> kind of being a junior csu attending
1814.48 -> rounding in the cicu and doing different
1817.039 -> procedural services what it looks like
1819.2 -> here at cleveland clinic was this was
1821.36 -> this was my pathway where um we had to
1824.24 -> suffice a certain number of um
1827.76 -> local medical icu months uh so that we
1830.72 -> could sit for uh abin certification so
1834.559 -> three months of the medical icu one
1836.48 -> month of nights one month of cicu one
1839.2 -> month of heart failure icu a couple
1841.279 -> months of cardiothoracic icu and then
1844 -> the rest of the time split between
1846 -> procedures airways
1848.24 -> and neuro
1850.799 -> um this slide i'm going to summarize and
1853.44 -> uh sorry this figure i'm going to
1854.799 -> summarize in this slide but
1856.96 -> several people do
1858.559 -> uh critical care or cardiology
1860.559 -> differently um
1862.32 -> i did the one-year medicine fellowship
1865.039 -> after general cardiology um but a lot of
1868.32 -> individuals have done a two-year
1870.559 -> critical care medicine first prior to
1872.399 -> general cardiology fellowship so you do
1874.799 -> three years of medicine residency two
1876.64 -> years of critical care medicine and then
1878.88 -> three years of general cardiology
1881.84 -> but i really believe that an ideal state
1885.12 -> should develop critical care within
1888.399 -> cardiology rather than start develop
1891.44 -> critical care cardiology within
1893.12 -> cardiovascular medicine
1895.039 -> rather than critical care medicine
1897.039 -> because cardiac critical care really
1899.2 -> becomes its own entity in the patients
1901.76 -> that come through the cicu
1904.159 -> and yes you need the airways and the
1905.76 -> bronx and the vents that you uh are
1908.96 -> otherwise missing from your skill set um
1912.24 -> but you need them
1913.919 -> in relation to the patient that you'll
1916.08 -> be taking care of the rest of your life
1917.679 -> so um kind of there's been discussions
1921.12 -> about unifying a four-year training
1923.039 -> program to streamline applications
1925.6 -> making sure that there's significant
1927.36 -> exposure to temporary mechanical support
1929.76 -> in the cardiothoracic and cicus
1932.96 -> a lot of individuals then look at well
1936.399 -> i've trained in critical care cardiology
1938.48 -> do i need to do anything else or
1941.76 -> how does the rest of my practice look
1944 -> and
1944.88 -> we can have a discussion about how
1947.039 -> critical care cardiology lends itself
1949.279 -> neatly to heart failure transplant
1952.24 -> i do know individuals who've done
1953.919 -> interventional training
1956.799 -> after their critical care year and i
1959.2 -> really emphasize after because you can
1961.44 -> imagine doing interventional training
1963.6 -> for a pgy7 year and then doing your
1966.399 -> critical care cardiology where you don't
1968.96 -> utilize any of the interventional skills
1971.039 -> you just obtained over the past year and
1973.44 -> can lead to skill atrophy so
1976.08 -> the order when it comes to
1977.519 -> interventional cardiology gets to be
1979.279 -> important so there are i feel naturally
1982 -> some
1982.88 -> a lesser number of individuals who do a
1986 -> triple pathway of cardiology
1988.399 -> interventional and critical care
1991.679 -> but this
1993.279 -> another venn diagram
1994.88 -> where i think that heart failure and
1996.559 -> critical care really lends itself nicely
1999.44 -> is
2000.48 -> in hemodynamics in shock in mechanical
2003.919 -> support in end of life care
2006.88 -> and
2008.48 -> looking at
2009.6 -> advancing the dynamics as well as
2012.72 -> kind of complex heart lung interactions
2014.799 -> i think
2015.919 -> there's a more natural pathway
2018.96 -> to these two disciplines
2022.24 -> but there al
2023.84 -> obviously is a
2025.76 -> pathway for the interventional
2027.679 -> intensivist who wants to
2030.159 -> put people on support devices such as
2032.32 -> via ecmo and do complex cannulations and
2035.36 -> structural interventions
2037.679 -> so that pathway still exists but
2040.48 -> as you'll see in a future slide a lot of
2042.72 -> individuals
2044.399 -> have naturally gravitated towards a
2046.799 -> heart failure plus critical care pathway
2050.879 -> i don't know if elliot's on the call but
2053.119 -> um he published
2055.04 -> an article in looking at what are
2057.119 -> the different components of each
2059.919 -> sub-specialty if you will
2062.639 -> and so this is adapted from
2065.28 -> his article
2066.96 -> but as you can see
2069.2 -> the things in critical care that we
2071.28 -> don't really have in cardiology really
2073.44 -> comes down to
2074.879 -> my
2075.919 -> in my opinion the most important really
2077.599 -> comes down to ventilators delirium
2080.28 -> antibiotics nutrition
2082.8 -> and some of these airway and pleural
2084.48 -> based procedures
2086.8 -> that we otherwise are missing in in
2089.28 -> routine cardiology
2091.76 -> so to me the ideal cardiac intensivists
2095.2 -> should feel comfortable with
2097.839 -> incompetent and temporary and durable
2100 -> support
2101.52 -> advanced airways and ventilators and
2103.2 -> complex heart lung interactions the
2105.119 -> ability to
2106.88 -> be comfortable with invasive procedures
2109.28 -> and kind of this perioperative
2111.839 -> management either bridging people to a
2114.16 -> destination or immediately taking care
2116.4 -> of complications in the post-operative
2118.48 -> setting
2119.599 -> and being able to manage multi-organ
2121.599 -> dysfunction in shock states
2124.96 -> along the way as you can imagine people
2127.119 -> thought well what is the advanced heart
2129.359 -> failure critical care cardiologists look
2131.44 -> like
2132.24 -> um so one of my current heart failure
2134.64 -> fellows
2136 -> and our cic director
2138.8 -> dr menin published this pathway which
2141.44 -> essentially just is an amalgam of
2144.48 -> everything that i've done so far which
2146.4 -> is uh three years of general cardiology
2148.96 -> one year of critical care and one year
2150.48 -> of advanced heart failure transplant
2153.2 -> this
2154 -> generally generated some traffic on
2156.16 -> twitter just last week where
2159.359 -> a lot of people think well that's that's
2161.359 -> eight years that's a lot of time
2164 -> it's a lot of times it's a lot of money
2165.68 -> it's a lot of board certification
2168.24 -> is there a way to
2170.72 -> kind of
2172.72 -> be considered a heart failure
2174.96 -> intensivist or heart failure critical
2177.359 -> care doctor um
2179.52 -> with less time and less kind of
2182.48 -> sacrifice
2184.32 -> i you know i have thoughts on this and
2187.04 -> and i obviously am biased because i did
2189.68 -> uh specific years in training but i also
2192.4 -> do think that whatever this looks like
2194.64 -> right here this embedded cardiac
2196.4 -> critical care clinical and procedural
2198.16 -> training really gets to be important
2202 -> i don't think it's enough to say you can
2204.4 -> do several electives and be considered
2207.68 -> you know having this distinction in
2209.28 -> cardiac critical care
2211.28 -> and have that be sufficient obviously
2213.119 -> people there are different people who
2215.04 -> will feel more invested
2217.599 -> and
2218.88 -> trained in these pathways
2221.28 -> and spend more time but
2223.839 -> you also don't want to
2227.119 -> get a distinction in cardiac critical
2228.96 -> care yet not know what you're doing at
2230.8 -> the end of the day
2232.32 -> um so
2233.92 -> to me the bigger question really becomes
2236.32 -> no matter which pathway this takes
2238.48 -> whether your advanced heart failure and
2240.56 -> critical care aborted or you have a
2242.8 -> distinction it's what you're comfortable
2245.2 -> with doing for your patient at the end
2247.28 -> of the day so here's a kind of display
2249.68 -> of of the different types of things
2252.96 -> that i do on a daily basis
2255.359 -> and how my role is split as a heart
2257.76 -> failure intensivist
2259.359 -> so i provide procedural support for a
2261.359 -> cardiac icu whether it's intubations
2263.68 -> airways troubleshooting events
2266.24 -> usually that would have called for a
2269.359 -> pulmonary consultation uh and instead
2272.16 -> they kind of rely on me and my cardiac
2274.24 -> intensivist colleagues plural and
2276.24 -> peritoneal based procedures and kind of
2278.48 -> this
2279.359 -> temporary mechanical support
2280.88 -> interventional heart failure realm
2282.88 -> utilizing insurrective balloon pumps
2285.119 -> axillary interior balloon pumps i don't
2288.16 -> do impellas but
2290.16 -> our ct surgeons have involved me and one
2292.96 -> of my other cardiac intensivist
2294.4 -> colleagues that i'll show on the next
2296.24 -> slide in the cannulation of va akimo so
2298.72 -> that kind of comes into
2300.72 -> however
2301.92 -> you want to make the role uh and then my
2304.24 -> other split is in heart failure
2305.76 -> transplant and all that
2307.599 -> as
2308.72 -> as many of you do
2310.16 -> and then also in right heart cath and
2312 -> myocardial biopsies
2314.079 -> there aren't that many heart failure
2315.839 -> intensivists around
2318 -> from what i can tell and i'm probably
2320 -> missing individuals here's a
2323.359 -> list of individuals that i know of were
2325.599 -> board certified were born eligible in
2328.64 -> both
2329.92 -> heart failure and critical care and
2332.32 -> general cardiology
2334.56 -> then you can
2336.16 -> discuss and ask what each of these
2338.4 -> individuals do but for example i know
2340.32 -> jason
2341.839 -> um you know medical directs and rounds
2343.76 -> in both the cardiac icu as well as the
2346.24 -> cardiothoracic icu jillian who was one
2349.2 -> of my co-fellows or said henry ford she
2351.76 -> rounded in the mickey for a very long
2353.52 -> time and recently gave that up but it's
2355.92 -> still very involved
2357.44 -> with the pulmonary department with
2359.119 -> respect to pulmonary hypertension
2361.68 -> so
2362.4 -> you can
2364.16 -> see that
2365.599 -> a lot of our job responsibilities and
2368.24 -> skill sets
2369.52 -> are also melded to the institution and
2371.76 -> what the institution needs as well
2375.119 -> um i'm going to skip this and really
2377.119 -> just talk about
2378.96 -> scholarship and
2380.56 -> what i think
2381.76 -> the ideal state should be and then we
2384.32 -> can open up for q a but here are some
2387.28 -> examples where kind of the future of
2390.24 -> heart failure and critical cardiology
2392.64 -> really lends itself too nicely which is
2395.2 -> what are optimal support devices what's
2397.2 -> the optimal timing for patients in
2398.8 -> cardiogenic shock what's the optimal
2400.72 -> resource utilization we talked about
2402.4 -> patients who are being bridged to
2404.079 -> transplant or
2405.52 -> being housed in the icu for
2408 -> evaluations for advanced therapies
2410.56 -> what's the impact of protocols and best
2412.48 -> practices and
2414.24 -> you know prevention of icu complications
2417.28 -> there are also opportunities in design
2419.52 -> and staffing which we'll talk about as
2421.52 -> well as different levels of nursing
2423.119 -> expertise and
2424.88 -> kind of bed management and best practice
2426.56 -> protocols
2428.079 -> so i'll wrap up with saying
2430.24 -> here's what i think the ideal cardiac
2432.72 -> icu really should be or at least should
2435.04 -> be equipped to handle in the future so a
2438.96 -> cic with appropriate admission and
2440.72 -> triage guidelines a multi-disciplinary
2443.359 -> team
2444.64 -> and that consists of intensivists
2447.04 -> cardiology consultants
2448.88 -> obviously trainees nursing pharmacy
2451.839 -> nutrition palliative medicine and social
2454.48 -> work indeed really the ability to care
2456.64 -> for patients in shock with
2459.2 -> any level of mechanical circulatory
2461.04 -> support the ability for
2463.359 -> care of non-post-surgical lvap patients
2467.68 -> to receive critical care cardiology
2470.319 -> and the ability to use on-site procedure
2472.48 -> room with fluoroscopic capabilities
2476.16 -> the ideal cicu should implement rigorous
2479.119 -> protocols order sets quality and safety
2481.599 -> dashboards um have routine meetings
2484.8 -> about how to you know maintain a high
2488.16 -> functioning organization um
2490.96 -> doing team-based activation protocols
2492.8 -> whether that's a pe response team a
2494.8 -> cartogenic shock team
2496.64 -> a hub and spoke model
2498.56 -> and really kind of furthering the
2500.079 -> subspecialty for interested trainees
2504.319 -> and then from a national standpoint
2506.4 -> integrating into existing nationwide
2508.319 -> databases
2509.599 -> talking about different registries
2511.68 -> expanding our knowledge of kind of this
2513.599 -> critically ill population and how it's
2516.24 -> changing
2518.48 -> in the country as well as changing us as
2520.839 -> providers and really expanding the
2523.2 -> scholarship
2524.48 -> around clinical operations and shock
2527.359 -> and really what we need to do to further
2529.599 -> grow the field
2531.92 -> so with that i think we still have 15
2534 -> minutes
2535.28 -> i wanted to end there and kind of
2537.92 -> open the forum up for discussion
2546.48 -> um wow that was really really good um i
2550.079 -> really enjoyed that talk
2551.76 -> so thank you so much i i have some
2553.68 -> questions but as always i'd like to
2555.359 -> defer to like the crowd to see if
2557.599 -> anybody would like to ask dr lee a
2559.92 -> question um
2561.76 -> and then i can follow if we run out of
2564.16 -> questions
2565.28 -> uh just feel free to meet yourself and
2567.44 -> raise your hand if you want me to call
2568.64 -> on you and
2569.68 -> um and if you have any questions for dr
2571.599 -> lee
2585.04 -> all right well i guess i will get things
2586.319 -> started
2587.52 -> so um
2589.599 -> a couple of things and a lot i was
2590.8 -> writing down a lot of notes and then a
2592.079 -> lot of the questions i was i was coming
2594.16 -> up with you were answering as your talk
2595.839 -> went on um so that was great but
2598.079 -> um so
2599.2 -> you know i completely understand like
2600.96 -> the need obvious you know to have
2602.8 -> somebody who is
2604.4 -> competent and thoroughly trained uh in
2606.88 -> these roles if you want to call yourself
2608.88 -> a critical care cardiologist but
2611.04 -> what do you think about you know um
2613.839 -> uh you know cardiologists or even
2615.599 -> advanced heart failure cardiologists
2617.04 -> that might be
2618.319 -> you know a decade out of training for
2619.76 -> example and um where this option for
2623.2 -> training and critical care cardiology
2624.88 -> may not have existed
2626.64 -> uh previously but
2628.8 -> they really enjoy making critical care a
2631.2 -> part of their their their practice and
2634.48 -> would not want to be left out of future
2636.88 -> opportunities to work in such a setting
2638.72 -> how how would how would you think would
2640.48 -> be the best way to to allow those people
2642.48 -> to
2643.44 -> uh gather additional training uh to make
2645.68 -> sure at least you know they're meeting
2647.04 -> the milestones that need to be met but
2649.52 -> also understanding they're already
2651.2 -> practicing cardiologists with a lot of
2653.68 -> other things on their hands
2655.52 -> no that's a very good question and i
2657.28 -> think that's what we are
2659.76 -> um
2661.04 -> not quite dealing with that's not the
2662.8 -> right way to put it but we're we're
2664.24 -> facing that here where you know i showed
2667.44 -> two of us currently on staff on the
2670.079 -> third has uh has has left
2672.4 -> the institution but two of us on staff
2674.64 -> um
2675.92 -> are
2677.04 -> you know
2677.839 -> certified in critical care cardiology or
2680.4 -> critical hair medicine at the very least
2682.96 -> but our heart failure icu hasn't changed
2686.24 -> so dramatically where
2689.119 -> kind of those skills on a day by day
2691.76 -> basis are in full force and the reality
2694.48 -> on the ground is that
2696.079 -> there just aren't as many cardiac
2698.48 -> intensivists even though it is a
2700 -> burgeoning specialty and people are very
2702.319 -> interested in it we aren't able to
2704.88 -> provide kind of the day-to-day service
2706.96 -> unless you want to be in the heart
2708.8 -> failure icu
2710.48 -> half the year and so i think the the
2712.8 -> conditions on the ground obviously
2715.359 -> will still dictate that there is still
2718.4 -> role for the heart failure cardiologist
2721.119 -> in the icu
2723.119 -> as it pertains to many academic centers
2726.24 -> and
2728.56 -> many kind of hybrid centers as well to
2731.28 -> get your question of well in the future
2733.52 -> if that paradigm and that volume of
2736.16 -> distribution changes does that make a
2738.8 -> difference and how do we get interested
2741.52 -> advanced heart failure folks
2743.76 -> to still be able to provide care in the
2746.079 -> heart failure icu and still be able to
2748.16 -> round
2749.2 -> i think it really comes down to
2751.839 -> the education and the competency based
2755.44 -> aspect so for example
2758.8 -> i i have a couple of of cardiac surgeons
2761.599 -> who are really old school here who don't
2763.68 -> necessarily believe in the concept of a
2765.44 -> shop team um
2767.839 -> do they take call
2769.839 -> do they take shot call i should say um
2772.72 -> and and how does that work um so i think
2776.8 -> for
2777.68 -> the
2778.64 -> future of
2780.24 -> an icu or heart failure icu kind of
2783.04 -> laying out
2784.68 -> institutional and unit-based practices
2787.2 -> and protocols and routine meetings and
2789.2 -> competencies and educational models
2792.88 -> really become important in kind of
2795.119 -> incorporating those interested heart
2797.599 -> failure cardiologists who still want to
2799.76 -> be part of the game
2801.44 -> to be up to date
2803.52 -> and i think that's the way to to bring
2805.2 -> people along the question
2807.359 -> um
2808.24 -> there there's also been talk about well
2811.44 -> in 10 years time will the acc and
2814.839 -> avim uh
2816.16 -> be
2817.52 -> allowed to grandfather people in uh to a
2821.04 -> certification and that kind of goes down
2822.72 -> to the distinction part i think that's
2824.8 -> to be determined and i think that really
2827.599 -> kind of depends on
2829.119 -> again what do you intend to do in the
2831.52 -> cardiac intensive care unit or the heart
2833.599 -> failure intensive care do you want to be
2836.16 -> the person providing
2838.319 -> advanced airway support and mechanical
2840.8 -> ventilatory support and
2842.72 -> troubleshooting waveforms and things
2844.4 -> like that or do you feel comfortable
2846.96 -> calling on your pulmonary or your micu
2849.119 -> colleagues to do so um obviously every
2852.64 -> place is going to be different in how
2854.4 -> they respond to that so i think it's
2856.319 -> hard to make a large societal uh change
2860.319 -> based on all right i'm just listening to
2862.48 -> a conference
2870.64 -> any any other uh questions
2874.64 -> yes
2875.68 -> uh thanks dr lee for your presentation
2877.68 -> it was very impressive
2879.52 -> we appreciate a lot especially since we
2882.079 -> are about to change
2883.68 -> our ccu dynamics here something i
2887.68 -> don't know
2889.44 -> or it's hard for me to anticipate is how
2892.48 -> the dynamics between the
2894.4 -> new
2895.52 -> cardio critical care team and the heart
2897.359 -> failure team is going to be
2899.44 -> i know that the sergeants may be more
2901.92 -> familiar with
2903.359 -> this concept of
2905.04 -> having
2906.8 -> as being a role of consultant was
2909.92 -> so being sort of
2911.839 -> the primary attending
2914.559 -> but from our standpoint i'm concerned
2916.72 -> about
2918 -> who would make the final decisions when
2920.319 -> it comes to transfusion a patient that
2922.319 -> is post transplant maybe rejecting or is
2925.92 -> pre-transplanted
2927.599 -> may have a borderline hemoglobin uh who
2930.4 -> will be having the final word about
2932.96 -> ionotropes presses types of mcs that
2936.24 -> we're going to escalate to because it's
2938.72 -> natural but
2940.079 -> some people may have disagreements
2942.48 -> yeah
2943.52 -> that's a very good question sorry
2946 -> so in your experience in the different
2947.76 -> institutions where you've worked
2951.2 -> how does it uh
2953.76 -> who has this final things
2957.68 -> i think um
2960.48 -> at the end of the day
2962.24 -> the primary team
2964.4 -> still has ownership of their patients
2966.4 -> and consultants
2968.079 -> at least at our institution are still
2970.319 -> viewed as consultants and and so that
2972.96 -> gets to be
2974.24 -> um
2975.599 -> that can lead to some disagreements
2977.599 -> where you know our heart failure
2979.839 -> cardiologist may come in and think the
2981.68 -> patient needs an escalation of support
2984.559 -> to a device
2986.24 -> and the cardiac intensivists may
2988.4 -> disagree with that or trying to bridge
2991.04 -> someone to transplant
2992.72 -> we have seen that tension here
2995.119 -> i will say
2997.2 -> a lot of our cardiac intensivists
3000.559 -> here as well as just the cardiologists
3003.119 -> around in the icu really defer to
3006.24 -> expertise at the same time and defer to
3009.2 -> the world that we live in because
3011.599 -> i and you may have knowledge of the
3016 -> universe allocation and different status
3019.599 -> and meeting different
3021.28 -> dynamic criteria
3023.68 -> but a lot of our individuals or a lot of
3026.079 -> our colleagues and
3027.599 -> who are in cardiac critical care even
3029.68 -> may not be up to date
3031.52 -> and so
3032.48 -> having that open line of communication
3034.079 -> gets to be really important um i do
3036.96 -> think at the end of the day
3040 -> primary teams are still primary teams
3041.839 -> and that's how we still operate
3043.839 -> and so
3045.76 -> a lot of times that will lead to issues
3048.72 -> and
3049.839 -> contention
3051.68 -> but
3053.04 -> i think providing education and
3055.04 -> expertise and consultation gets to be
3058 -> the art of being a consultant
3061.2 -> so
3062 -> i do think that it's easier at least
3064.64 -> from the perspective of we speak
3067.2 -> a very similar language we speak a
3069.359 -> cardiology trained language whereas i
3072.079 -> found a lot of difficulty with my
3074.079 -> anesthesia critical care colleagues
3075.76 -> because they come from a different
3076.96 -> background and their understanding of
3079.359 -> human dynamics than we do
3082 -> even my miku colleagues also kind of
3084.64 -> come from a different background of
3087.52 -> understanding or interpreting human
3089.68 -> dynamics especially with regards to
3092.48 -> kind of the more non-invasive modalities
3094.8 -> such as pocus and vti and things like
3097.839 -> that
3099.28 -> so knowing that we all come from
3100.72 -> different places and different training
3102.24 -> backgrounds
3103.52 -> kind of helps with that but i think in
3106.319 -> from a cardiac intensive care and heart
3108 -> failure intensive care or heart failure
3110 -> training perspective um you at least
3112.4 -> have a similar base to talk through
3116 -> in a lot of this but we see those
3118.72 -> kind of disagreements happen
3121.52 -> here as well
3126.8 -> another question when you're rounding us
3129.44 -> a
3130.24 -> cardio creep or car attending the
3132.72 -> ccu or in the heart failure or cu
3136.96 -> is there also another
3139.119 -> cardio critical care tending assigned to
3141.119 -> the heart failure icu or is there also
3145.28 -> a redundance on
3147.76 -> on the heart failure consultant that
3149.839 -> would see certain patients in the
3152.48 -> ccu because since you're boarded on both
3156.4 -> yeah um that's a good question and i
3158.559 -> think that's mainly unique to me uh
3161.599 -> oftentimes i will represent the heart
3164.96 -> failure section
3166.72 -> um
3168 -> on a given patient and we won't call for
3171.839 -> a consultation
3173.28 -> um and i'll you know present the patient
3176.24 -> to the committee or to my colleagues
3180.16 -> where i've found
3182.48 -> that i do need to involve a heart
3184.96 -> failure or my colleagues in heart
3186.88 -> failure on a single patient really comes
3189.28 -> down to
3190.4 -> making sure that if there's
3192.64 -> any question of candidacy it does and
3195.839 -> and it's a little bit gray
3198.16 -> it doesn't look like
3199.839 -> i have
3201.04 -> the complete say over someone so for
3202.8 -> example if someone who's you know been
3205.839 -> actively abusing substances and is a
3208.079 -> poor candidate for advanced therapies i
3210.319 -> don't need to consult my colleagues to
3211.92 -> kind of come say that because it's a
3213.52 -> pretty clear cut but if it's
3215.839 -> you know is this a patient who is
3219.68 -> a candidate for a back-up level of
3222.16 -> support for example they're going
3224.079 -> undergoing a valvular intervention with
3226.24 -> open-heart surgery and the question
3228.559 -> becomes on the back end if they fail
3231.28 -> their temporary support impella during
3234 -> surgery
3235.28 -> could they be a candidate for a durable
3237.04 -> bat down the line we get that consult
3239.119 -> not infrequently in those situations i
3241.839 -> might ask for another set of eyes so it
3244.72 -> doesn't look like
3246.24 -> i'm making
3247.52 -> several decisions for the patient that
3249.839 -> may have a little bit of gray
3252.079 -> and i would want to make sure at least
3253.44 -> in the medical record it doesn't appear
3255.359 -> that way that i'm necessarily biased or
3258 -> one way or the other for a patient
3260.64 -> um but for the most part a lot of the
3263.599 -> kind of routine heart failure
3264.8 -> consultations that happen in the cardiac
3267.04 -> icu
3268.48 -> go by the wayside when i round in the
3270.24 -> cardiac icu and so my split is you know
3272.72 -> i do about six weeks of cardiac icu
3274.96 -> rounding and then the other four to five
3278 -> weeks out of the year are spent between
3280.24 -> the heart failure icu as well as the
3281.68 -> heart failure floors and so i do have a
3284.96 -> nice diverse mix of job responsibility
3293.28 -> any other comments out there
3299.76 -> well if not i know we're getting uh to
3301.359 -> the top of the hour so i'm sure
3303.28 -> everybody has something else scheduled
3304.799 -> at four o'clock so i just want to again
3307.359 -> uh thank dr ryan lee for taking the time
3309.68 -> to put together this wonderful
3310.799 -> presentation for us and um
3313.2 -> sharing it's something i think that
3315.44 -> i mean i've i've learned a lot from
3317.28 -> today and i'm very excited to see how we
3319.44 -> might be able to implement some of these
3321.76 -> ideas uh into our own program our
3324 -> clinical program here at yale
3326 -> and um you know getting getting to pick
3328.799 -> your brain somebody who has expertise
3330.72 -> like this this is a great opportunity
3332.4 -> for us so thank you so much yeah anytime
3334.799 -> and i think um what i'm seeing uh not
3337.68 -> just in yale but other places are people
3340.079 -> are interested in kind of cicu design
3342.799 -> and how to staff so at any point in time
3345.04 -> if you have any questions i'm happy to
3346.799 -> answer um obviously not being there not
3349.599 -> knowing exactly how your dynamics work
3351.28 -> on a day-by-day basis but providing any
3353.52 -> input i'm happy to so thank you for the
3355.599 -> invitation i really enjoy talking to you
3357.359 -> all all right thanks
3359.359 -> all right everybody have a great rest of
3360.64 -> your day
Source: https://www.youtube.com/watch?v=9CC4lyhwOf8